Healthcare Provider Details

I. General information

NPI: 1225949688
Provider Name (Legal Business Name): KYLA CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 UNIVERSITY DR
VIRGINIA BEACH VA
23453-8001
US

IV. Provider business mailing address

728 WINCHESTER RD
BROOMALL PA
19008-3431
US

V. Phone/Fax

Practice location:
  • Phone: 318-578-2514
  • Fax:
Mailing address:
  • Phone: 318-578-2514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN681115
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: